AJMC: payers demand outcomes
- The current flashpoint is not a single drug approval but a reimbursement fight: payers and drugmakers are demanding proof that diabetes and obesity medicines improve real-world outcomes enough to justify rising costs. - The sharpest new example came in Australia, where Eli Lilly ended talks to list Mounjaro on the Pharmaceutical Benefits Scheme, leaving about 450,000 patients paying hundreds of dollars a month. - The backdrop is a broader shift from trial efficacy to access, persistence, and claims-based outcomes, with GLP-1 coverage under heavier scrutiny in 2026. (ajmc.com)
Payers are asking a harder question about diabetes and obesity drugs: not whether they work in trials, but whether they deliver enough value in everyday care to merit coverage. (ajmc.com) That shift has been building for years in managed care. AJMC reported as early as July 21, 2014, that drugmakers were moving from proving safety and efficacy alone toward proving comparative effectiveness and cost-effectiveness to health plans. (ajmc.com) The practical tool is claims data: de-identified medical, pharmacy, and lab records that let payers and manufacturers see which patients drive costs, who stays on treatment, and where complications fall. (ajmc.com) That old debate has become immediate with glucagon-like peptide-1 drugs, or GLP-1s, and related medicines such as tirzepatide. AJMC said last week that new payer research presented at the Academy of Managed Care Pharmacy 2026 meeting tied the real-world impact of obesity drugs to coverage and persistence, not just prescriptions written. (ajmc.com) One claims-based study in Massachusetts Medicaid, published in the Journal of Managed Care & Specialty Pharmacy in March 2026, found 60.8% persistence and 60.1% adherence at six months among 7,493 adults starting semaglutide or tirzepatide. (jmcp.org) The reimbursement pressure is visible outside the U.S. too. 7NEWS reported on April 25, 2026, that Eli Lilly walked away from negotiations to add Mounjaro to Australia’s Pharmaceutical Benefits Scheme, leaving about 450,000 Australians without discounted access. (7news.com.au) Without that listing, patients were expected to keep paying hundreds of dollars a month out of pocket, according to 7NEWS. The dispute turned on price, not whether tirzepatide lowers blood sugar or weight. (7news.com.au) Another branch of the same argument is what happens after patients stop the drugs. ClinicalTrials.gov shows Fractyl Health’s REMAIN-1 study is testing whether an outpatient endoscopic procedure, Revita duodenal mucosal resurfacing, can limit weight regain after patients first lose at least 15% of body weight on tirzepatide. (clinicaltrials.gov) The trial record says the randomized cohort will compare Revita with a sham procedure after tirzepatide is discontinued, with a midpoint analysis after about 45 patients and a pivotal analysis planned in about 315 patients. (clinicaltrials.gov) Dartmouth’s Geisel School of Medicine highlighted interim findings on February 5, 2026, quoting professor Shelby Sullivan saying Revita patients in the study kept losing weight while sham patients regained it rapidly. (geiselmed.dartmouth.edu) The common demand across these stories is measurable durability. Payers want evidence on access, refill behavior, long-term outcomes, and downstream costs before they agree to broad coverage for expensive chronic therapies. (ajmc.com 1) (ajmc.com 2) For drugmakers, that means the sales pitch is changing from “the trial hit its endpoint” to “patients stayed on therapy, avoided complications, and reduced total spending.” The drugs may be the same, but the proof payers want is now much closer to the real world. (ajmc.com)
